Impact on pregnant/parturient women's health resulting from displacement between residence and health service

Objective: to analyze the impact on pregnant/parturient women's obstetric and neonatal outcomes resulting from displacement between homes and health services. Methods: an integrative review was carried out in August 2020 on the following databases: SCOPUS, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online/PubMed, Science Direct and Latin American and Caribbean Health Sciences Literature/Virtual Health Library, using controlled descriptors and keywords. Besides, a quantitative descriptive analysis of the main results was performed using the Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires software. Results: the sample resulted in 20 articles. It was evidenced that the mobility of women is hampered by distance between home and health services, precarious transport, and living in socioeconomically disadvantaged places. Conclusion: difficulty in mobility is a crucial factor that explains the adverse maternal and neonatal impact. Descriptors: Health; Health Impact Assessment; Pregnant Women; Health Services; Locomotion. RESUMO Objetivo: analisar o impacto relacionado ao deslocamento das gestantes/parturientes entre suas residências e os serviços de saúde no desfecho obstétrico e neonatal. Métodos: revisão integrativa, cuja busca foi realizada em agosto de 2020 nas bases: SCOPUS, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online/PubMed, Science Direct e Literatura Latino-Americana e do Caribe em Ciências da Saúde/Biblioteca Virtual em Saúde, utilizando descritores controlados e palavras-chave. Além disso, foi realizada análise descritiva quantitativa dos principais resultados no software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires. Resultados: a amostra resultou em 20 artigos. Foi evidenciado que a mobilidade entre o domicílio e os serviços de saúde é dificultada pela distância, precariedade nos transportes, residência em locais socioeconomicamente desfavorecidos, dentre outros. Conclusão: a dificuldade na mobilidade é um fator chave que explica o impacto negativo materno e neonatal. Descritores: Saúde; Avaliação do Impacto na Saúde; Gestantes; Serviços de Saúde; Locomoção. 1Universidade Federal do Ceará. Fortaleza, CE, Brazil. Corresponding author: Mônica Oliveira Batista Oriá Rua Alexandre Baraúna, 1115 Rodolfo Teófilo. CEP: 60430-160. Fortaleza, CE, Brazil. E-mail: profmonicaoria@gmail.com EDITOR IN CHIEF: Viviane Martins da Silva ASSOCIATE EDITOR: Francisca Diana da Silva Negreiros Ivana Rios Rodrigues1 Luiz Belino Ferreira Sales1 Mônica Oliveira Batista Oriá1 Maria Luziene de Sousa Gomes1 Nádya dos Santos Moura1 How to cite this article: Rodrigues IR, Sales LBF, Oriá MOB, Gomes MLS, Moura NS. Impact on pregnant/parturient women's health resulting from displacement between residence and health service. Rev Rene. 2021;22:e61115. DOI: https://doi.org/10.15253/2175-6783.20212261115 Rodrigues IR, Sales LBF, Oriá MOB, Gomes MLS, Moura NS Rev Rene. 2021;22:e61115. 2 Introduction The pregnancy-puerperium cycle brings with it biopsychosocial changes and, for this reason, health professionals must accompany pregnant, parturient, and puerperal women. This is considered a fundamental condition to protect and prevent adverse events related to maternal and child health, allowing the identification and management of timely clinical procedures on the risk factors that impact mothers and their babies(1). Access to health care is an essential factor in assisting the mother-child dyad, and several determinants must be considered, including availability, acceptability, financial accessibility, and geographical accessibility(2). In this study, geographic accessibility is emphasized, as research on the geographical proximity of women’s homes to health services is considered an important factor for favorable obstetric and neonatal outcomes(3). In literature searches, no statistical data were found associated with unfavorable conditions related to geographic accessibility, which evidences a gap in the knowledge of how geographic access to health services impact obstetric and neonatal outcomes. Thus, the study is relevant to the extent that it is deemed necessary to deepen whether maternal and neonatal health outcomes are more favorable when attributed to geographic access and consequent improvement concerning the displacement between homes and health services. Therefore, the study’s objective was to analyze the impact on pregnant/parturient women’s obstetric and neonatal outcomes resulting from displacement between homes and health services.


Introduction
The pregnancy-puerperium cycle brings with it biopsychosocial changes and, for this reason, health professionals must accompany pregnant, parturient, and puerperal women. This is considered a fundamental condition to protect and prevent adverse events related to maternal and child health, allowing the identification and management of timely clinical procedures on the risk factors that impact mothers and their babies (1) . Access to health care is an essential factor in assisting the mother-child dyad, and several determinants must be considered, including availability, acceptability, financial accessibility, and geographical accessibility (2) .
In this study, geographic accessibility is emphasized, as research on the geographical proximity of women's homes to health services is considered an important factor for favorable obstetric and neonatal outcomes (3) .
In literature searches, no statistical data were found associated with unfavorable conditions related to geographic accessibility, which evidences a gap in the knowledge of how geographic access to health services impact obstetric and neonatal outcomes.
Thus, the study is relevant to the extent that it is deemed necessary to deepen whether maternal and neonatal health outcomes are more favorable when attributed to geographic access and consequent improvement concerning the displacement between homes and health services. Therefore, the study's objective was to analyze the impact on pregnant/parturient women's obstetric and neonatal outcomes resulting from displacement between homes and health services.

Methods
This is an integrative literature review conducted in five steps: question formulation, literature search for primary studies, study evaluation, analysis, and reporting (4) . This method was considered the most appropriate for exploring the existing literature available from scientific sources. Besides that, to support the data analysis, the IRAMUTEQ software was used allowing different processing and statistical analysis of texts (5) . From the texts selected for analysis, IRAMU-TEQ makes an association enabling the grouping of statistically significant words for the studied context.
For the processing of data, a word cloud was used, grouped, and organized graphically according to the word frequency, which quickly enable the identification of words from a single file called corpus, which brings together the texts originated from the main results of the selected articles (5) .
From the concern to understand the phenomenon, a guiding question was elaborated using the PICo strategy as follows: participants (P), pregnant and parturient women; interest (I), obstetric and neonatal outcomes; and context (Co), displacement between home and health services. Therefore, the central question for conducting this review was: What is the impact of displacement between homes and health services on pregnant/parturient women's obstetric and neonatal outcomes?
After choosing the theme, the study search was carried out in August 2020 independently and concurrently by two researchers. There was no disagreement among the reviewers regarding the selection of articles. The search was carried out in the following databases: SCOPUS, Web of Science (WOS), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, Science Direct, and Latin American and Caribbean Health Sciences Literature (LILACS) via Virtual Health Library (VHL).
The intersection of controlled descriptors and keywords was mediated by the Boolean operators "AND" and "OR". No search filters or time limitations were used. There was also no manual search in the references of the extracted articles.
Primary articles were included addressing pregnant/parturient women's geographic access to health services, prenatal care, labor, delivery, and obstetric emergencies. Articles that addressed the quality of care for pregnant/parturient women in health services, letters, conference proceedings, and book chapters were excluded. After applying the inclusion and exclusion criteria, a sample of 20 articles ( Figure 1) was obtained, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRIS-MA) guidelines (6) .
An instrument was developed by the authors and used as scientific support to extract the relevant data from the articles. This instrument included the articles identification data, the host institution of the study, the type of scientific journal, methodological characteristics of the studies, and primary obstetric and neonatal outcomes.
The data analysis was performed descriptively. The results are presented according to the outcomes revealed in the studies. As this is an integrative review, primarily public domain studies were used, and thus approval from an institutional review board is not needed.
The main mobility barriers of pregnant/parturient women to maternal health services are related to distance, resulting in another important factor: travel time (which in obstetrics can be decisive for a timely intervention). Other barriers such as housing, lack of private transport, poor public transport, low income, and low education must be considered, especially in rural populations (7)(8)(9)(12)(13)16,18,22,(24)(25) .
It is also important to mention that, in addition to the mobility barriers, there are influencers that are related to the knowledge of pregnant women about the importance of performing prenatal care, the benefit of this for a favorable outcome in childbirth, populations living in urban areas (where the distance from the residence to the maternal health service is shorter than in rural areas), high income and schooling, and having a vehicle available to transport (8)(9)(10)(11)(13)(14)18,(20)(21)(22)(23) .

Reference Outcomes
Parkhurst; Ssengooba Uganda 2009 (7) Mobility: limited in areas furthest from maternal health services. Barriers (13) Mobility: precarious mobility in socioeconomically disadvantaged areas. Barriers: low income, residence in rural areas, distance, travel, lack of transport. Influencers: high income and educational level, residency in urban areas, ethnicity. Clinical outcome/Displacement impact: exposure to pregnancy complications.
Tsawe; Susuman South Africa 2014 (14) Mobility: precarious mobility in socioeconomically disadvantaged areas. Barriers: Shortage of staff, financial problems, and lack of knowledge. Clinical outcome/Displacement impact: the distance reduced women's trip to maternal health services, leaving them more exposed to prenatal care complications, labor, and delivery.
Okwaraji et al. Ethiopia 2015 (15) Mobility: facilitated to pregnant women with older age and who had higher education. Barriers: limited transport to pregnant women in rural households.  With its barriers and influencers, mobility from home to maternal health services affects the clinical outcomes of pregnant/parturient women. Studies show that these outcomes are related to complications during pregnancy, labor, and delivery, often performed unsafely at home and without professional assistance. Besides, clinical changes in pregnant wo-men, such as respiratory distress, lower limb edema, and decompensated blood pressure, are outcomes of this process. Increases in maternal and fetal deaths are also mentioned and are the most unfavorable outcomes for women, families, and the community (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26) .
Concerning the descriptive and quantitative analysis of this review, Figure 3 displays the word
Barriers: people living in delta regions (close to rivers) have limited access to maternal health services, as they are socioeconomically disadvantaged.
Influencers: prenatal care and quality labor and delivery.
Clinical outcome/Displacement impact: unsafe births at home, edema, fetal death.

Panciera et al.
Bangladesh 2016 (20) Mobility: difficult in the most distant and socioeconomically disadvantaged areas.
Barriers: travel time, distance, low education, and income.
Influencers: pregnant women with an educational background; living close to health services.
Clinical outcome/Displacement impact: home births without professional assistance.
Barriers: travel time, distance.
Influencers: living close to health services.
Clinical outcome/Displacement impact: difficulty in accessibility and unsafe births.

Makanga et al.
Mozambique 2017 (22) Mobility: access for pregnant women to maternal health services by public transport or on foot.
Barriers: limited access to health services during periods of floods and precipitation.
Clinical outcome/Displacement impact: unsafe births, respiratory distress in pregnant women, lower limb edema, decompensated blood pressure, and fetal death.
Chen et al.
Tanzania 2017 (23) Mobility: public or private transportation, or on foot.
Barriers: distance and travel time from homes to maternal health services.

Influencers: pregnant women who own vehicles.
Clinical outcome/Displacement impact: poor prenatal care, home births without professional assistance, increased maternal and perinatal deaths.

Wang et al.
Haiti 2017 (24) Mobility: limited in areas furthest from maternal health services.

Influencers: residing in urban areas.
Clinical outcome/Displacement impact: home births, with a risk of complications.

Yasuoka et al.
Cambodia 2018 (25) Mobility: comparison of the actual distance and the straight line the pregnant woman travels to perform prenatal care.
Influencers: education and knowledge about the recommended frequency for consultations.
Clinical outcome/Impact of displacement: only highly educated women and those who live close to maternal health services arrived to perform prenatal care promptly.
Barriers: travel time; distance.
Clinical outcome/Displacement impact: the displacement between home and health services has improved in Uganda, decreasing maternal and perinatal deaths. cloud built from the word cloud's grouping and graphic organization. It is possible to perform the identification of keywords. Figure 3 shows the words positioned randomly so that the most frequent words are displayed more boldly and in larger font sizes than the rest; that is, it shows its prominence in the corpus of analysis.

Discussion
As an important result of this study, no previous research has been carried out in Brazil on pregnant/ parturient women's health impact resulting from displacement between residence and health services, highlighting an important knowledge gap. It is well known that riverine populations in the rural areas (and even in Brazilian capitals) have different levels of difficulties accessing health services. Thus, it was impossible to know how the displacement of pregnant/ parturient women to health centers has impacted national indicators of maternal and child health.
The study findings allow greater knowledge about the theme, highlighting the impact related to the care associated with the displacement of pregnant/parturient women between homes and health services. These findings can contribute to the development of strategies to improve access to health services, which is still a challenge. These strategies are related to better access to health services, which are mainly focused on roads, transport, and safer transport for people living in areas close to rivers.
The studies presented here are related to the mobility of pregnant/parturient women to health services and how this aspect affects women and children's health. In several countries, access to health services is still considered a challenge. Especially in Brazil's context, which guarantees universal and integral access to health in its constitution, realizing this right involves several and complex determinants that need to be better understood (27) .
Among these determinants, mobility is influenced by 1) the individual's need to use health services (demographic characteristics, social structure, and beliefs), 2) factors that allow and/or impede the full use of services (income, health insurance, availability of services, distance and waiting time), and 3) the individual's health needs. In summary, it arises from social and geographical aspects; that is, it can be influenced by situations of vulnerability, including human, physical, financial, and social capital aspects (27)(28)(29) . Therefore, this review highlighted aspects related to the mobility of pregnant/parturient women to health services, barriers, influencers, and their impact on women and children's health.
Studies show that in Mozambique (Southeast Africa) and Uganda (East Africa) when there are precipitations and floods, the traffic changes to make it difficult for women to access health services. They are unable to have professional care during pregnancy or childbirth (22,26,28) .
However, to minimize women's trips to health services when seasonal variation prevents them or when transport brings more risks to the mother and baby, assistance includes community health workers as a team. These workers are lay members of communities that work for remuneration and generally share ethnicity, language, socioeconomic status, and life experiences with the community members they serve (22,28) .
Variables such as education, maternal age, and personal or family income were significantly associated with travel time to the best quality health unit or the nearest health center (15,29) . The difficulty of mobility in emergency obstetric care is a crucial factor that explains why most births in rural regions still occur at home, without specialized care (29)(30) .
The parturients who live in rural areas have to travel to access maternity services, have higher rates of adverse results, and more extended stays of newborns (in days) in neonatal intensive care units (27) .
The distance measured in a real or straight-line appears as barriers for pregnant/parturient women to access health services (11,17,25,29) . The greater the distance, whether it is real or in a straight line, the greater the likelihood that women will not seek maternal health services and perform childbirth at home assisted by lay people (29) .
It can also be highlighted that the lack of knowledge and the low quality of maternal health services are barriers and determinants associated with the use of these services. These barriers are related to the lack of inclusion of the media in terms of information related to maternal health services and the importance of such services, scarcity of educational programs aimed at improving the literacy skills of women (especially in rural areas), lack of policies aimed at shaping women's livelihoods, and poor quality maternal health care in rural areas (14,30) .
From another perspective, women regularly seek prenatal care at health facilities. However, some factors prevent them from accessing these facilities promptly, which include social discouragement to reveal early pregnancy, lack of knowledge about the warning signs of pregnancy, poor transportation infrastructure, and fear of maltreatment in health facilities, which causes a discouraging impact for pregnant women and their partners and, consequently, lack of empowerment (30) .
Although the studies found in this review are limited to assessing mobility in rural areas, it is understood that mobility may also be impaired in large urban areas and that this compromises health and clinical outcomes.
The quantitative analysis performed from the word cloud showed that the clinical outcome of pregnant/parturient women reflects displacement. Therefore, the mother-child dyad's health is influenced by the woman's mobility between home and maternal health services, the quality of care provided by these services, the influencers related to the area in which the woman inhabits, and her limitations. The word cloud makes it possible to identify co-occurrences between words and their result indicates the connection between them, helping to identify the representation structure.
Although this review does not present data related to the mobility situation of pregnant/parturient women in the Brazilian context (which per se reveals a knowledge gap), the authors dare to reflect that Brazilian cities also have mobility difficulties that deserve to be evaluated, so that measures aimed at minimizing health impacts related to mobility can be implemented ensuring the right to come and go for all citizens.
This study also points out the need for further studies, especially in Brazil, which shows efforts to address the impact of pregnant women's displacement between their homes and maternal health services. Linking data sets using the geographic information system has the potential for future research and can help overcome the neglect of these health system factors in research and policy.
The difficulty in mobility to prenatal and obstetric emergency care is a crucial factor that explains the adverse maternal and neonatal impact that women may experience. Therefore, addressing geographical and quality of access barriers is crucial to increasing the quality of services and decreasing maternal and perinatal mortality.

Conclusion
The study showed that the difficulty of the mobility of pregnant/parturient women from residence to maternal health services is a crucial factor that explains adverse maternal and neonatal impacts including space, transportation, physical, social and economic infrastructure, revealing the impact on the health of the mother-child dyad, demonstrated by mobility barriers and influencers.